Community Connections Student Form

Student Application
Please fill out and submit the form below. The information you provide will be used to help us match you with a Community Host.
All fields required for submission. Please use N/A for not applicable
Name*
First Last
Home Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone*
Cell Phone*
Email*
Summer Address
- I have a different address in the summer
Summer Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Birth*
MM slash DD slash YYYY
Gender*
If you are not already on campus, what is your expected arrival date?*
MM slash DD slash YYYY
What are your academic interests?*
What is your major?*
What do you do for fun?*
If you have any food restrictions/allergies, please list:*
If you have a problem with family pets, please describe:*
Do you prefer a smoke-free environment?*
Do you speak any languages other than English? If so, please list.*
Do you have any special needs or concerns regarding Community Host placement?*
What would you most like your Community Host to do with/for you?*
If you are an international student, what is your country of citizenship?*
If you are an international student, have you been to the US before? If so, where?*
If you are an international student, have you studied in the US before? If so, where?*
Consent*
I have read the information use agreement associated with is form below.
By filling out this form and hitting submit you authorize us to share the information provided with the match committee and selected community hosts. Completing an application form does not guarantee a community connections placement.
Comments
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Community Connections Student Form

Student Application

Deborah Roark